A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Rationale:

A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.

B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.

C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.

D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.

E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.

Rationale:

A. Palpate for possible bladder distention is a task that requires nursing assessment skills and should be done by the nurse.

B. Observe the incision site is a nursing task that involves assessing for signs of complications.

C. Change the abdominal dressing requires sterile technique and should be done by a nurse to prevent infection and ensure proper care.

D. Obtain vital signs is within the AP’s scope of practice and is a task that can be delegated. It is important for monitoring the client’s status and identifying potential issues.